Chapter 4: When Breathing Stops: CPR and the Defibrillator

What Can Happen

At the end of a session at a day centre, a care worker is helping a man in his seventies into his coat. He says he feels strange, sits down heavily on a chair by the door and then slides to the floor. The care worker kneels beside him and calls his name, but he does not answer. His eyes are half open, and now and then he makes a slow, snoring gasp. A colleague runs over and asks what to do. In that moment, everything the two of them have practised comes down to a few clear actions: call for help, push hard and fast on the chest, and fetch the defibrillator.

When a person's heart suddenly stops pumping blood, the person collapses, stops responding and stops breathing normally. Without help, the brain is quickly starved of oxygen, and what the people nearby do in the first minutes can make the difference between life and death. This chapter explains how to recognise that a person needs cardiopulmonary resuscitation, which most people call CPR, how to give chest compressions and rescue breaths, and how to use an automated external defibrillator. It also covers taking turns, knowing when to stop, and how a person's own wishes are respected through the care plan. These are skills that every care worker can learn, and they are well within your reach.

Knowing When CPR Is Needed

Chapter 3 explained how to check a person who has collapsed: make sure the area is safe, see whether the person responds to your voice and a gentle tap on the shoulders, shout for help, open the airway with the head tilt and chin lift, and check breathing for no more than 10 seconds. If the person does not respond and is not breathing normally, start CPR. You do not need to feel for a pulse, and first aid courses for the public do not ask you to. A person who does not respond and is not breathing normally needs CPR, and that is enough to act on.

The hardest part is often judging the breathing. In the first minutes after the heart stops, many people make occasional gasps, slow snoring sounds or jerky movements of the jaw. These gasps can look like breathing, but they are not normal breathing, and they are a sign that the heart has stopped. Some people also have a brief jerking of the arms and legs as they collapse, which can look like a seizure. If you are not sure whether the breathing is normal, act as if it is not and start CPR. Courses teach this because the risk of harm from CPR to a person whose heart is still beating is small, while waiting when the heart has stopped costs the person precious time.

Chest compressions keep some blood flowing to the brain and the heart while the heart cannot pump by itself. They buy time, but on their own they usually cannot restart the heart. When a heart stops suddenly, it is often quivering in a chaotic rhythm, and an automated external defibrillator can give an electric shock that may let it return to a normal beat. That is why the emergency call, chest compressions and the defibrillator belong together, and why each one should start as early as possible. First aid courses describe this as a chain of help: an early call, early CPR and early use of the defibrillator, followed by the care that paramedics and the hospital give.

As soon as you know that the person is not breathing normally, call the emergency number or ask someone else to call, and ask another person to bring the defibrillator if there is one nearby. If you are alone, call with your phone on speaker and put it beside the person's head, so that you can start compressions while you talk. The emergency operator can coach you through each step and, in some places, can tell you where the nearest public defibrillator is. Your workplace will also have procedures for an emergency on site, such as who brings the defibrillator, who meets the ambulance and who looks after the other people you support. Follow them as you have practised.

Step by Step: Chest Compressions

Step 1. Make sure that the person is lying on their back on a firm, flat surface. Compressions work poorly on a soft mattress or in a chair, because the surface gives way instead of the chest. If the person is in a chair or a wheelchair, lower the person to the floor as quickly and gently as you can, with others helping if possible, as Chapter 3 explains. If the person is in bed and cannot be moved to the floor safely, start on the bed and follow your workplace's procedures and the operator's instructions. Beside a road, make sure first that traffic cannot reach you, as Chapter 9 explains.

Step 2. Kneel beside the person's chest. Place the heel of one hand in the centre of the chest, on the lower half of the breastbone. Put the heel of your other hand on top of the first and lace your fingers together, keeping your fingers off the ribs. You can give compressions through thin clothing, so do not lose time undressing the person at this stage.

Step 3. Lean over the person so that your shoulders are directly above your hands, and keep your arms straight. Press straight down, using the weight of your upper body rather than the strength of your arms. Push the chest down about 5 to 6 centimetres in an adult. This feels deep, and it is meant to.

Step 4. After each push, let the chest come all the way back up before you press again, while keeping your hands in place on the chest. The heart fills with blood as the chest rises, so leaning on the chest between compressions makes them less effective.

Step 5. Keep a steady rate of 100 to 120 compressions per minute. This is a brisk rhythm, and counting aloud helps you and anyone helping you to keep it. In older people, ribs may crack during compressions, even when they are done correctly. If you feel or hear this, keep going at the same depth and rate, because without compressions the person cannot survive.

Step 6. If you have been trained in rescue breaths and are willing to give them, give 30 compressions and then 2 rescue breaths, and repeat this pattern. To give a breath, open the airway with the head tilt and chin lift, pinch the soft part of the nose closed, take a normal breath, seal your lips around the person's mouth and blow steadily until you see the chest rise. Let the chest fall, then give the second breath in the same way. Use a face shield or a pocket mask from your first aid kit if you have one, and keep the pause for breaths short.

Step 7. If a breath does not make the chest rise, look in the mouth, take out anything you can clearly see, and adjust the head tilt and chin lift before the next breath. Do not try more than 2 breaths before going back to compressions. If you are not trained in rescue breaths, or you are not willing to give them, give hands-only CPR: continuous compressions at the same depth and rate without stopping. Hands-only CPR given well is far better than no CPR at all.

Step 8. Keep going with as few pauses as possible. Stop only when a paramedic or another trained person takes over, when the defibrillator tells you not to touch the person, when the place becomes unsafe, when you are too exhausted to go on, or when the person starts breathing normally and shows other signs of life, such as coughing, opening their eyes or moving on purpose. If the person starts breathing normally but does not wake up, put the person in the recovery position as Chapter 3 describes, keep checking the breathing, and be ready to start CPR again.

Step by Step: Using an Automated External Defibrillator

Step 1. Ask someone to bring the defibrillator as soon as you know the person is not breathing normally, and keep giving compressions until it arrives. Place the machine beside the person and switch it on; some machines switch on when the lid is opened. From this moment, listen to the machine's voice and follow it. A defibrillator for public use is designed for people with no medical training, and it will not give a shock unless the heart rhythm needs one.

Step 2. While one person keeps giving compressions, the other uncovers the person's chest. Open or cut the clothing, using the scissors in the defibrillator kit if needed, and move or remove a bra if it is where the pads must go. Work quickly, but keep the person covered as much as you can, out of respect for the person's dignity. If the chest is wet, for example from sweat on a hot day or from rain, wipe it dry. If there is thick hair where a pad must go, some kits include a razor to remove it quickly.

Step 3. Peel the pads off their backing and stick them firmly to the bare skin in the places shown in the pictures on the pads. Usually one pad goes just below the person's right collarbone, and the other goes on the left side of the chest, below the armpit. If the person has a lump under the skin from an implanted device, such as a pacemaker, place the pad a little away from the lump. Press each pad down well so that it makes full contact with the skin.

Step 4. When the machine says that it is analysing the heart rhythm, stop compressions and make sure that nobody is touching the person. Say it out loud, for example "Everyone stand clear", and look along the person's body to check. Touching or moving the person can disturb the analysis.

Step 5. If the machine advises a shock, check again that nobody is touching the person, then press the shock button when the voice tells you to. Some machines give the shock by themselves after a warning. If the machine says that no shock is advised, it does not mean that the person is better. It means that a shock will not help at that moment and that compressions are needed.

Step 6. Straight after the shock, or after a "no shock" message, start compressions again at once, as the voice tells you. Leave the pads in place and the machine switched on, even if the person starts to recover. The machine will check the heart rhythm again at regular intervals and tell you when to stand clear. Keep following its instructions and the emergency operator's until the paramedics take over.

Taking Turns, Keeping Going and Respecting Wishes

Good chest compressions are tiring, and they become shallower without the rescuer noticing. If more than one person can give compressions, take turns, changing over each time the defibrillator stops to analyse the rhythm. Without a machine, change over just as regularly, before the person giving compressions tires. Make the change quickly, with the next person already kneeling on the other side of the chest, so that the pause is as short as possible. Other helpers can talk to the operator, go out to meet the ambulance, or take care of the other people you support.

CPR can be upsetting to see and to do. The person's face may look grey, the person may vomit, and ribs may crack. If the person vomits, turn the person onto their side for a moment so that the vomit can drain from the mouth, wipe the mouth, then turn the person onto their back and continue. Remember that the person's heart has already stopped, and that by giving CPR you are giving the person a chance they would not otherwise have. Talk to each other calmly and keep going. Afterwards, your own feelings matter too, and Chapter 15 describes the support that is available.

Some people you support will have made decisions with their doctors and families about whether they want resuscitation. These decisions are written in the care plan and in the records your workplace keeps. Know where this information is for each person before an emergency happens, and follow the care plan and your workplace's procedures exactly. Whatever the decision, you still call for help, stay with the person and keep them comfortable. If there is no clear decision recorded, or you cannot find it quickly, start CPR and tell the emergency operator and the paramedics what you know. Respecting a person's wishes and acting quickly are both part of good care, and preparing in advance lets you do both.

Reading these steps is a good start, but CPR is a physical skill. The depth, the rhythm and the position of your hands are learned with your own hands, by practising on a manikin in a practical first aid course with a trainer who can correct you. Many training manikins show whether your compressions are deep enough and fast enough. Skills fade over time, so refresher courses and short practice sessions at work keep them ready. If your workplace has a defibrillator, ask to open it and hear its voice during training, so that the first time you use it is not the day you need it.

Things to Check

Check where the nearest defibrillator is in each place where you work and along the routes you take with the people you support. Public places such as stations, shops and sports centres often have one, and knowing where it is saves precious time.

Check that your workplace's defibrillator is ready to use: its light or display shows that it is working, the pads are sealed and within their expiry date, and the battery is in order. Report any problem at once, as your workplace's procedure says.

Check that the kit kept with the defibrillator includes disposable gloves, a face shield or a pocket mask, scissors that can cut clothing, a razor and a small towel. These small items make the first steps faster.

Check that you know where each person's care plan records any decision about resuscitation, and that the information is up to date. Ask your supervisor about anything that is unclear.

Check that the emergency number of the country where you work, learned from official information, is saved in your phone, and that you can switch your phone to speaker quickly while your hands are busy.

Check the date of your last practical first aid course. If your training is no longer fresh, ask about a refresher course and about practice at work with a manikin and a training defibrillator.

Check that your team has agreed who does what in an emergency on site: who calls, who brings the defibrillator, who meets the ambulance and who stays with the other people you support.