Community-based cardiopulmonary resuscitation: what have we learned?

During the past 9 years, more than 175,000 residents of Seattle have received basic training in cardiopulmonary resuscitation (CPR). On the basis of experience in that city and of observations from three other communities, there is little doubt that early initiation of CPA by a bystander is associated with a substantially improved survival. In one year, 43% of patients (47/109) found in a state of ventricular fibrillation survived to hospital discharge when bystanders initiated CPR. In comparison, only 21% (43/207) lived when CPR was delayed until fire department personnel arrived on the scene (p less than 0.001). As expected, there are questions regarding community CPR programs, particularly concerning the level of skills attained and retained. However, in the setting of a rapid-response emergency-care system, we have been unable to relate survival to the apparent quality of CPR as judged by the bystanders' training and occupation or by assessment of what was done on the scene. This discrepancy is likely related to the rapid initial response of the fire department, averaging 3 minutes from dispatch to arrival on the scene. It is important to emphasize that CPR is almost always a temporizing measure and that most victims who require CPR will also need defibrillation, special airway management, and administration of medications. In patients with out-of-hospital ventricular fibrillation, the factors that determine survival are predominantly related to the rapidity with which care is provided, namely, the time from collapse to initiation of CPR and the time to provision of advanced life-support measure. In many communities a 50% survival rate from ventricular fibrillation is probably attainable. Further improvement might accrue from the extensive deployment of inexpensive defibrillators capable of detecting ventricular fibrillation and suitable for use by the general public.