Public Access Defibrillation

Abstract

The value of early intervention in critically ill patients has long been recognized. As early as the 1700s, scientists recognized the value of mouth-to-mouth respiration and the medical benefits of electricity (1). In the modern era, advances in resuscitation began to proliferate. In 1947, Claude Beck successfully resuscitated a 14-year-old boy through the use of open chest massage and an alternating current (AC) defibrillator, the kind that is used in wall outlets. In 1956, Paul Zoll demonstrated the effectiveness of closed chest massage with the use of an AC defibrillator. In the late 1950s, Peter Safar, William Kouwenhoven, James Jude and others began to study sudden cardiac arrest (CA) and in 1960, they demonstrated the efficacy of mouth-to-mouth ventilation and closed chest cardiac massage (2). In 1961, Bernard Lown demonstrated the superiority of direct current (DC) defibrillators, the kind provided by batteries. In 1966, J. Frank Pantridge and John Geddes developed the world’s first mobile intensive care unit (MICU) in Belfast, Northern Ireland, as a way to bring early advanced medical care to patients with cardiac emergencies (3). In 1969, William Grace established the first MICU in the United States in New York City (4). Subsequently, there were efforts in the United States and throughout the world to emulate and build on this concept. In the late 1960s and early 1970s, paramedic programs were developed by Eugene Nagel in Miami, Leonard Cobb in Seattle, Leonard Rose in Portland, Michael Criley in Los Angeles, and James Warren and Richard Lewis in Columbus. In the 1980s, Mickey Eisenberg, Richard Cummins, and colleagues demonstrated the effectiveness of rapid defibrillation in Seattle, Washington (5), while Kenneth Stults demonstrated the same in rural Iowa (6). This growing body of research demonstrated the importance of rapid care for victims of sudden CA by showing that survival improved when basic life support (mouth-to-mouth ventilation and closed chest compressions) was provided within 4 minutes and advanced life support (defibrillation, intravenous medications and fluids, and advanced airway management) within 8 minutes. Subsequent studies found that the benefits of advanced life support were primarily the result of electrical countershock for patients in ventricular fibrillation (VF). From these findings, a model of care called the “Chain of Survival,” was first described by Mary Newman (7), and then by Cummins et al. (8), and eventually adopted by the Citizen CPR Foundation, the American Heart Association (AHA) and others. The Chain of Survival consists of four action steps that must occur in rapid succession to provide the patient the greatest likelihood for resuscitation: early access (call 911 or the local emergency number to notify the emergency medical services [EMS] system and summon on-site help); early cardiopulmonary resuscitation (CPR; begin immediately); early defibrillation; and early advanced care (transfer care to EMS professionals upon their arrival at the scene).