Basic Life Support Cardiopulmonary Resuscitation BLS CPR 2 Kings, Chap. 4, . !4, that "li#ah $...

h $... %ent up, and lay upon the child, and put his mouth upon his mouth, and his eye upon his eyes, and his hands upon his hands& and he stretched himself upon the child' and the flesh of the child %a(ed %arm. )*+), ,r. -riedeich .aass successfully performed e(ternal chest compression on a human. )+/!, the first successful resuscitation using e(ternal chest massage 0y ,r. 1eorge Crile. )+2/s %hen the research team of ,rs. Peter Safar and 3ames "lam made the 0iggest leaps for%ard 0y demonstrating that e(pired air could pro ide ade4uate o(ygenation follo%ed in )+24 0y the deli ery of mouth5to5mouth resuscitation %ith predicta0le results. )+6/, ,r. Kou%enho en et al perfected the techni4ue for closed5chest massage, the last piece of the pu77le %as put into place. .odern cardiopulmonary resuscitation 8CPR9 %as 0orn, and consistent results %ere finally achie a0le.2

:;.<= B>,? Body Systems Respiratory System it deli ers o(ygen to the 0ody a s%ell as remo es car0on dio(ide from the 0ody. @he passage of air into and out of the lungs is called respiration. Breathing in is called inspiration, 0reathing out is called e(piration. Circulatory System it deli ers o(ygen and nutrients to the 0ody tissues and remo es %aste products. At consists of the heart, 0lood essels and 0lood. =er ous System composed of the 0rain spinal cords and ner es.

Breathing and Circulation <ir that enters and lungs contains& B 2)C >2 B D+C nitrogen and other mi(ed gases <ir e(haled from lungs contains& B)DC >2 B4C C>2 Relationship of :ypo(ia to Brain -unction /54 minutes 0rain damage unliEely 456 minutes damage pro0a0le 65)/ minutes 5 0rain damage is certain

C<R,A>F<SC;L<R ,AS"<S" .yocardial Anfarction 8:eart <ttacE9 >ccurs %hen the o(ygen supply to the heart muscle 8myocardium9 is cut off for a period of time resulting into reduced 0lood supply due to narro%ing and or complete 0locEage of a diseased artery

resulting in death of the muscle tissue supplied 0y the essel. RisE -actors for Cardio ascular ,isease RisEs that can not 0e changed 8non modifia0le9 B :eredity B<ge B1ender RisE factors that can 0e changed 8modifia0le9 BCigarette smoEing B:@= B"le ated cholesterol and triglyceride le els BLacE of e(ercise B>0esity BStress B,. KA=,S >- LA-" S;PP>R@ Basic Life Support (BLS) <n emergency procedure that consist of recogni7ing respiratory or cardiac arrest or 0oth and the proper application of CPR to maintain life until a ictim reco ers or ad anced life support is a aila0le. BLS includes recognition of signs of sudden cardiac arrest 8SC<9'heart attacE, stroEe, and foreign50ody air%ay o0struction 8-B<>9cardiopulmonary resuscitation 8CPR9' and defi0rillation %ith an automated e(ternal defi0rillator 8<",9. Advanced Cardiac Life Support (ACLS) An addition to BLS, it utili7es drugsGmedications and special e4uipment to maintain 0reathing and circulation C:<A= >- S;RFAF<L "arly access and recognition of the emergency and acti ation of the emergency medical ser ices 8".S9 or local emergency response system& Hphone +)).I "arly CPR 5 .ost effecti e %hen started immediately after collapse and can dou0le or triple the ictimJs chance of sur i al from SC<. "arly ,efi0rillation CPR plus defi0rillation %ithin ! to 2 minutes of collapse can produce sur i al rates as high as 4+C to D2C. "arly <CLS follo%ed 0y postresuscitation care deli ered 0y healthcare pro iders.

CPR5 Cardio Pulmonary Resuscitation CPR is a series of sEill assessments and inter entions CPR pro ides a small 0ut critical amount of 0lood flo% to the heart and 0rain. -or e ery minute %ithout CPR, sur i al from %itnessed SC< decreases DC to )/C. CPR has 0een sho%n to dou0le or triple sur i al from %itnessed SC< at many inter als to defi0rillation.

R"SC;" BR"<@:A=1 Rescue breathing a techni4ue of 0reathing air into a persons lungs to supply a patient %ith >2. K<?S @> F"=@AL<@" @:" L;=1S Mouth-to-Mouth Rescue Breathing >pen the ictimJs air%ay, pinch the ictimJs nose, and create an airtight mouth5to5mouth seal. 1i e ) 0reath o er ) second, taEe a HregularH 8not a deep9 0reath, and gi e a second rescue 0reath o er ) second. @aEing a regular rather than a deep 0reath pre ents you from getting di77y or lightheaded. @he most common cause of entilation difficulty is an improperly opened air%ay, so if the ictimJs chest does not rise %ith the first rescue 0reath, perform the head tilt5chin lift and gi e the second rescue 0reath. Mouth-to-Barrier Device Breathing Barrier de ices may not reduce the risE of infection transmission, and may increase resistance to air flo%. < aila0le in 2 types& B -ace Shields and -ace .asEs. -ace shields are clear plastic or silicone sheets that reduce direct contact 0et%een the ictim and rescuer 0ut do not pre ent contamination of the rescuerJs side of the shield. BSome masEs include an o(ygen inlet for administration of supplementary o(ygen. B .asEs used for mouth5to5masE 0reathing should contain a )5%ay al e that directs the rescuerJs 0reath into the patient %hile di erting the patientJs e(haled air a%ay from the rescuer. Mouth-to-Nose and Mouth-to-Stoma enti!ation .outh5to5nose entilation is recommended if it is impossi0le to entilate through the ictimJs mouth 8eg, the mouth is seriously in#ured9. @he mouth cannot 0e opened, the ictim is in %ater, or a mouth5to5mouth seal is difficult to achie e. 1i e mouth5to5stoma rescue 0reaths to a ictim %ith a tracheal stoma %ho re4uires rescue 0reathing. <n alternati e is to create a tight seal o er the stoma %ith a round pediatric face masE. enti!ation "ith Bag a!ve Mas# < 0ag5masE de ice pro ides positi e5pressure entilation. ,eli er each 0reath o er a period of ) second and pro ide sufficient tidal olume to cause isi0le chest rise. Capa0le of creating a tight seal co ering 0oth mouth and nose. .asEs should 0e fitted %ith an o(ygen inlet, ha e a standard )25mmG225mm connector, and should 0e a aila0le in one adult and se eral pediatric si7es. At may produce gastric inflation and its complications. .asEs should 0e made of transparent material to allo% detection of regurgitation. K:? BLS5CPR

Sudden cardiac arrest 8SC<9 is a leading cause of death in the ;nited States and Canada. CPR should 0e pro ided until an ".S or an automated e(ternal defi0rillator 8<",9 or manual defi0rillator is a aila0le. <ge ,elineation ,ifferences in the etiology of cardiac arrest 0et%een child and adult ictims necessitate some differences in the recommended resuscitation se4uence for infant and child ictims compared %ith the se4uence used for adult ictims.

Differences in CPR for Lay Rescuers and Healthcare Providers La$ Rescuer @he lone rescuer should telephone the emergency response system and retrie e an <", 8if a aila0le9. @he rescuer should then return to the ictim to 0egin CPR and use the <", %hen appropriate. @he lay rescuer should open the air%ay and checE for normal 0reathing. Af no normal 0reathing is detected, the rescuer should gi e 2 rescue 0reaths. Ammediately after deli ery of the rescue 0reaths, the rescuer should 0egin cycles of !/ chest compressions and 2 entilations and use an <", as soon as it is a aila0le. Lay rescuers are not taught to assess for pulse or signs of circulation for an unresponsi e ictim. Lay rescuers %ill not 0e taught to pro ide rescue 0reathing %ithout chest compressions -or the unresponsi e infant or child, the lay rescuer se4uence for action is as follo%s& @he rescuer %ill open the air%ay and checE for 0reathing' if no 0reathing is detected, the rescuer should gi e 2 0reaths that maEe the chest rise. @he rescuer should pro ide 2 cycles 8!/ compressions & 2 0reaths9 of CPR, a0out 2 minutes. Lea e the pediatric ictim to phone +)) and get an <", for the child if a aila0le. %ea!thcare &rovider @he lone healthcare pro ider should alter the se4uence of rescue response 0ased on the most liEely etiology of the ictimJs pro0lem. -or suddenG%itnessed, collapse in ictims of all ages, the lone healthcare pro ider should telephone the emergency response num0er and get an <", 8%hen readily a aila0le9 and then return to the ictim to 0egin CPR and use the <",. Call first. -or unresponsi e ictims of all ages %ith liEely asphy(ial arrest 8eg, dro%ning9 the lone healthcare pro ider should deli er a0out 2 cycles 8a0out 2 minutes9 of CPR 0efore lea ing the ictim to telephone the emergency response num0er and get the <",. @he rescuer should then return to the ictim, 0egin the steps of CPR, and use the <",. Call fast. <fter deli ery of 2 rescue 0reaths, :C should attempt to feel a pulse in the unresponsi e, non0reathing ictim not more than )/ seconds. Af no pulse %ithin )/ seconds, 0egin cycles of chest compressions and entilations. :C %ill 0e taught to deli er rescue 0reaths %ithout chest compressions for the ictim %ith respiratory arrest and a perfusing rhythm 8ie, pulses9. Rescue 0reaths %ithout chest compressions should 0e deli ered at a rate of a0out )/ to )2 0reaths per minute for the adult and a rate of a0out )2 to 2/ 0reaths per minute for the infant and child. >nce an ad anced air%ay is in place for infant, child, adult ictims, 2 rescuers no longer deli er compressions interrupted %ith entilation. Compression should 0e deli ered at )// compressions per minute continuously, %ithout pauses for entilation. @he rescuer deli ering the entilations should gi e * to )/ 0reaths per minute.

=>@"L B@he 2 rescuers should change compressor and entilator roles 4 2 minutes to pre ent compressor fatigue and deterioration in 4uality and rate of chest compressions. BKhen multiple rescuers are present, they should rotate the compressor role a0out e ery 2 minutes. @he s%itch should 0e accomplished as 4uicEly as possi0le 8ideally in less than 2 seconds9 to minimi7e interruptions in chest compressions. S"M;"=C" >- <C@A>= ). Sur ey the scene 2. @aEe time to sur ey the scene and ans%er these 4uestions& As the scene safeN personal safety, 0ody su0stance isolation precautions, safety of patient, safety of 0ystanders Khat happenedN 5 mechanism of in#ury or nature of illness trauma or medical. :o% many people are in#uredN sur ey the scene for num0er of patients and determine additional resources needed <re there any 0ystanders %ho can help meN Adentify your self as trained BLS pro ider 1et consent to care Perform Primary Sur ey >nce the rescuer has ensured that the scene is safe, checE for responseGconsciousness. !. @o checE for response, asE the ictim $Sir <re you >KI 4. Af there is no response, tap the ictim on the shoulder and asE, H<re you all rightNH 2. Af the ictim responds 0ut is in#ured or needs medical assistance, lea e the ictim to phone +))G 8))D9. Return as 4uicEly as possi0le and rechecE the ictimJs condition fre4uently. 6. Af there is no response at all, mo e to <BC. <BC5, < ChecEG>pen <ir%ay B:ead tilt chin lift B.odified #a% thrust LR @he lay rescuer should open the air%ay using a head tilt5chin lift maneu er for in#ured and non5in#ured ictims. @he #a% thrust is no longer recommended for lay rescuers 0ecause it is difficult for lay rescuers to learn and perform, is often not an effecti e %ay to open the air%ay, and may cause spinal mo ement. :C < healthcare pro ider should use the head tilt5chin lift maneu er to a ictim %ithout e idence of head or necE trauma. D. >pen the <ir%ay and ChecE Breathing @o prepare for CPR, place the ictim on a hard surface in supine position. Af an unresponsi e ictim is prone, roll the ictim to supine. B 5 ChecE for Breathing B LooE listen and feel for no more than )/ sec. B =oteL a. Af ictim is 0reathing or resumes effecti e0reathing, place in reco ery position. 0. Af ictim is not 0reathing, gi e 2 0reaths that maEe chest rise.

c. Release completely allo% for e(halation 0et%een 0reaths. LR LooE for normal 0reathing. @his should help the lay rescuer distinguish 0et%een the ictim %ho is 0reathing 8and does not re4uire CPR9 and the ictim %ith agonal gasps 8%ho is liEely in cardiac arrest and needs CPR9. An infant or child they should looE for the presence or a0sence of 0reathing. Should assess for ade4uate 0reathing in the adult.

:C

Rescue Breaths @he purpose of entilation is to maintain ade4uate o(ygenation. 1i e 2 rescue 0reaths, each 0reath deli ered in ) second, %ith enough olume to produce isi0le chest rise. >ther ne% recommendations for rescue 0reaths are these& :ealthcare pro iders should pro ide effecti e 0reaths in infants and children. <sphy(ial arrest is more common than cardiac arrest in infants and children. An infant, if no chest rise and fall is noted during entilation, reopen and reposition the air%ay and reattempt entilation. @he rescuer may need to try a couple of times to deli er 2 effecti e 0reaths for the infant and child. Khen rescue 0reaths are pro ided %ithout chest compressions to a ictim %ith a pulse, the healthcare pro ider should deliver 12 to 20 breaths/minute - infant or child 10 to 12 breaths/ minute - adult. "ach 0reath should 0e gi en o er ) second regardless of %hether an ad anced air%ay is in place. "ach 0reath should cause isi0le chest rise. < oid deli ering 0reaths that are too large or too forceful. At may may cause gastric inflation and its resultant complications C 5 ChecE for CirculationGCompression

HC B ChecE pulse for no more than )/ sec. B Carotid in child and adult, 0rachial and femoral infant B Af pulse is present 0ut 0reathing is a0sent, Pro ide rescue 0reathing& ) 0reath 4 2 to 6 sec for adults, ) 0reath 4 ! to 2 sec for infants or child. B RechecE pulse 4 2 minutes B Af pulse is a0sent, 0egin chest compressions if no definite pulse after )/ seconds. B Cycles of !/ compressions and 2 0reaths until <", or <LS arri es. B -or infants, if pulse is present 0ut less than 6/ 0pm, 0egin chest compressions. LR B LR %ill not checE pulse on ictims B Lay rescuers fail to recogni7e the a0sence of a pulse in )/C of pulseless ictims 8poor sensiti ity for cardiac arrest9 and fail to detect a pulse in 4/C of ictims %ith a pulse 8poor specificity9. B -or ease of training, the lay rescuer %ill 0e taught to assume that cardiac arrest is present if the unresponsi e ictim is not 0reathing

Chest Compression < rhythmic applications of pressure o er the lo%er half of the sternum. Creates 0lood flo% 0y increasing intrathoracic pressure and directly compressing the heart. Blood flo% generated 0y chest compressions deli ers a small 0ut critical amount of o(ygen and su0strate to the 0rain and myocardium. Pts %ith F- SC<, chest compressions increase the liEelihood that defi0rillation %ill 0e successful. Chest compressions are especially important if the first shocE is deli ered 4 minutes after collapse. @echni4ue @o ma(imi7e the effecti eness of compressions& @he ictim should lie supine on a hard surface 8eg, 0acE0oard or floor9 %ith the rescuer Eneeling 0eside the ictimJs thora(. Compress the lo%er half of the ictimJs sternum in the center 8middle9 of the chest, 0et%een the nipples. Place the heel of the hand on the sternum in the center 8middle9 of the chest 0et%een the nipples and then place the heel of the second hand on top of the first so that the hands are o erlapped and parallel. ,epress the sternum appro(imately ) to 2 inches 8appro(imately 4 to 2 cm9 and allo%ing complete chest recoil that allo%s enous return to the heart. Compression and chest recoilGrela(ation time should 0e e4ual. Lay rescuers should continue CPR until an <", arri es, the ictim 0egins to mo e, or ".S personnel taEes o er CPR. Lay rescuers should no longer interrupt chest compressions to checE for signs of circulation or response. :ealthcare pro iders should interrupt chest compressions as infre4uently as possi0le, limit interruptions to no longer than )/ seconds e(cept for inter entions such as insertion of an ad anced air%ay or use of a defi0rillator. At is recommended that patients not 0e mo ed %hile CPR is in progress unless the patient is in a dangerous en ironment or is a trauma patient in need of surgical inter ention . Khen 2 or more rescuers are a aila0le, it is reasona0le to s%itch the compressor a0out e ery 2 minutes 8or after 2 cycles of compressions and entilations at a ratio of !/&29. " ery effort should 0e made to accomplish this s%itch in O2 seconds. Af the 2 rescuers are positioned on either side of the patient, one rescuer %ill 0e ready and %aiting to relie e the H%orEing compressorH e ery 2 minutes. 'nfant and Chi!d Lay rescuers and healthcare pro iders should deli er chest compressions that depress the chest of the infant and child 0y one third to one half the depth of the chest. Because children and rescuers can ary %idely in si7e, rescuers are no longer instructed to use a single hand for chest compression of all children. Anstead the rescuer is instructed to use ) hand or 2 hands 8as in the adult9 as needed to compress the childJs chest to one third to one half its depth. LR& should use a !/&2 compression5 entilation ratio for all 8infant, child, and adult9 ictims. :C& should use a !/&2 compression5 entilation ratio for all )5rescuer and all adult CPR and should use a )2&2 compression5 entilation ratio for infant and child 25rescuer CPR.

ConclusionGfindings on research presented at the 2//2 Consensus Conference a0out chest compressions& H"ffecti eH chest compressions are essential for pro iding 0lood flo% during CPR @o gi e Heffecti eH chest compressions, Hpush hard and push fast.H Compress the adult chest at a rate of a0out )// compressions per minute, %ith a compression depth of ) to 2 inches 8appro(imately 4 to 2 cm9. <llo% the chest to recoil completely after each compression, and allo% appro(imately e4ual compression and rela(ation times. .inimi7e interruptions in chest compressions. -urther studies are needed to define the 0est method for coordinating entilations and chest compressions and to identify the 0est compression5 entilation ratio in terms of sur i al and neurologic outcome. , ,efi0rillation 5 ,efi0rillation using <utomated e(ternal defi0rillators 8<",9 is an integral part of 0asic lifesupport.

SP"CA<L C>=SA,"R<@A>=S, Resuscitation Situations& Compression >nly CPR @he outcome of chest compressions %ithout entilations is significantly 0etter than the outcome of no CPR for adult cardiac arrest. Laypersons should 0e encouraged to do compression5only CPR if they are una0le or un%illing to pro ide rescue 0reaths, although the 0est method of CPR is compressions coordinated %ith entilations. ,ro%ning Rescuers should pro ide CPR, particularly rescue 0reathing, as soon as an unresponsi e su0mersion ictim is remo ed from the %ater. Khen rescuing a dro%ning ictim of any age, the lone healthcare pro ider should gi e 2 cycles 8a0out 2 minutes9 of CPR 0efore lea ing the ictim to acti ate the ".S system. .outh5to5mouth entilation in the %ater may 0e helpful %hen administered 0y a trained rescuer. Chest compressions are difficult to perform in %ater, may not 0e effecti e, and could potentially cause harm to 0oth the rescuer and the ictim. Rescuers should remo e dro%ning ictims from the %ater 0y the fastest means a aila0le and should 0egin resuscitation as 4uicEly as possi0le. >nly ictims %ith o0 ious clinical signs of in#ury or alcohol into(ication or a history of di ing, %aterslide use, or trauma should 0e treated as a Hpotential spinal cord in#ury,H %ith sta0ili7ation and possi0le immo0ili7ation of the cer ical and thoracic spine. Some ictims aspirate nothing 0ecause they de elop laryngospasm or 0reath5 holding. <ttempts to remo e %ater from the 0reathing passages 0y any means other than suction 8eg, a0dominal thrusts or the :eimlich maneu er9 are unnecessary and potentially dangerous.

:ypothermia Se ere hypothermia 0ody temperature O!/PC Q*6P-R, associated %ith marEed depression of critical 0ody functions that may maEe the ictim appear clinically dead during the initial assessment An some cases hypothermia may e(ert a protecti e effect on the 0rain and organs in cardiac arrest An an unresponsi e hypothermic pt, :C should assess 0reathing and pulse for !/ to 42 seconds 0ecause heart rate and 0reathing may 0e ery slo%, depending on the degree of hypothermia. Af the ictim is not 0reathing, initiate rescue 0reathing immediately. Af the ictim does not ha e a pulse, 0egin chest compressions immediately. Af there is any dou0t a0out %hether a pulse is present, 0egin compressions. ,o not %ait until the ictim is re%armed to start CPR. Pre ent further heat loss, remo e %et clothes' insulate or shield the ictim from %ind, cold' and if possi0le, entilate the ictim %ith %arm, humidified o(ygen. < oid rough mo ement. @ransport the ictim to a hospital as soon as possi0le. -or the hypothermic patient in cardiac arrest, continue resuscitati e efforts until the patient is e aluated 0y ad anced care pro iders. R".".B"R& < patient is not dead until he is %arm and dead.

Fomiting 0y the Fictim ,uring Resuscitation @he ictim may omit %hen the rescuer performs chest compressions or rescue 0reathing. < )/5year study in <ustralia, t%o thirds of ictims %ho recei ed rescue 0reathing and *6C of ictims %ho re4uired compressions and entilations omited. Af omiting occurs, turn the ictimJs mouth to the side and remo e the omitus using your finger, a cloth, or suction. Af spinal cord in#ury is possi0le, logroll the ictim so that the head, necE, and torso are turned as a unit. CPR in Pregnancy ,uring attempted resuscitation of a pregnant %oman, pro iders ha e t%o potential patients, the mother

and the fetus. @he 0est hope of fetal sur i al is maternal sur i al. -or the critically ill patient %ho is pregnant, rescuers must pro ide appropriate resuscitation, %ith consideration of the physiologic changes due to pregnancy. <t 2/ %eeEs of gestation and 0eyond, the pregnant uterus can press against the inferior ena ca a and the aorta, impeding enous return and cardiac output. ;terine o0struction of enous return can produce prearrest hypotension or shocE and may precipitate arrest in the critically ill patient. An cardiac arrest the compromise in enous return and cardiac output 0y the gra id uterus limits the effecti eness of chest compressions. @he gra id uterus may 0e shifted a%ay from the inferior patient )2P to !/P 0acE from the left lateral position ena ca a and the aorta 0y placing the

or 0y pulling the gra id uterus to the side. @his may 0e accomplished manually or 0y placement of a rolled 0lanEet or other o0#ect under the right hip and lum0ar area. @o treat the pt& Place the patient in the left lateral position. 1i e )//C o(ygen. "sta0lish intra enous 8AF9 access and gi e a fluid 0olus. Consider re ersi0le causes of cardiac arrest and identify any pree(isting medical conditions that may 0e complicating the resuscitation.

-oreign5Body <ir%ay >0struction 8ChoEing9 ,eath from -B<> is an uncommon 0ut pre enta0le cause of death. .ost reported cases of -B<> in adults are caused 0y impacted food and occur %hile the ictim is eating. .ost reported episodes of choEing in infants and children occur during eating or play, %hen parents or childcare pro iders are present. Commonly %itnessed, and the rescuer usually inter enes %hile the ictim is still responsi e. Recognition of -oreign5Body <ir%ay >0struction Signs of se ere air%ay o0struction include& Signs of poor air e(change and increased 0reathing difficulty.

Silent cough, cyanosis, or ina0ility to speaE or 0reathe. @he ictim clutches his necE, demonstrating the uni ersal choEing sign. <sE, H<re you choEingNH Af the ictim indicates HyesH 0y nodding his head %ithout speaEing, this %ill erify that the ictim has se ere air%ay o0struction. Relief of -oreign5Body <ir%ay >0struction ,o not interfere %ith the spontaneous coughing and 0reathing efforts. <ttempt to relie e the o0struction only if & the cough 0ecomes silent, respiratory difficulty increases and is accompanied stridor, or the ictim 0ecomes unresponsi e. 0y

<cti ate the ".S 4uicEly if the patient is ha ing ,>B. Af more than one rescuer is present, one rescuer should phone +)) 8))D9 %hile the other rescuer attends to the choEing ictim. <0dominal thrust must 0e applied in rapid se4uence until the o0struction is relie ed. Af a0dominal thrusts are ineffecti e, consider chest thrusts. <0dominal thrusts are not recommended for infants O) year of age 0ecause it may cause in#uries. Chest thrusts should 0e used instead of a0dominal thrusts for o0ese patients if the rescuer is una0le to encircle the ictimJs a0domen. Af the choEing ictim is in the late stages of pregnancy' Fictims of -B<> treated %ith a0dominal thrusts should 0e encouraged to undergo an e(amination 0y a physician for in#ury. Af the adult ictim %ith -B<> 0ecomes unresponsi e, carefully support the patient to the ground, immediately acti ate ".S, and then 0egin CPR. :C pro ider should use finger s%eep only %hen he can see solid material o0structing the air%ay.