Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX G n Skills
STEP 1.
D—Details (name, demographics, type of
film, date, and time)
STEP 2. R—RIPE (assess image quality)
••
Rotation
••
Inspiration—5–6 ribs anterior in midclavicular
line or 8–10 ribs above diaphragm,
poor inspiration, or hyperexpanded
••
Picture (are entire lung fields seen?)
••
Exposure penetration
STEP 3. S—Soft tissues and bones. Look for
subcutaneous air and assess for fractures
of the clavicles, scapulae, ribs (1st and 2nd
rib fractures may signal aortic injury),
and sternum.
STEP 4. A—Airway and mediastinum . Look for signs
of aortic rupture: widened mediastinum,
obliteration of the aortic knob, deviation of
the trachea to the right, pleural cap, elevation
and right shift of the right mainstem
bronchus, loss of the aortopulmonary
window, depression of the left mainstem
bronchus, and deviation of the esophagus to
the right. Look for air in the mediastinum.
STEP 5. B—Breathing, lung fields, pneumothoraces,
consolidation (pulmonary contusion),
cavitary lesions
STEP 6. C—Circulation, heart size, position borders
shape, aortic stripe
STEP 7. D—Diaphragm shape, angles, gastric bubble,
subdiaphragmatic air
STEP 8. E—Extras: endotracheal tube, central
venous pressure monitor, nasogastric tube,
ECG electrodes, chest tube, pacemakers
STEP 1.
Needle Decompression
Assess the patient’s chest and respiratory status.
STEP 2. Administer high-flow oxygen and ventilate
as necessary.
intercostal space midclavicular line is
appropriate.) For adults (especially with
thicker subcutaneous tissue), use the fourth
or fifth intercostal space anterior to the
midaxillary line.
STEP 4. Anesthetize the area if time and physiology
permit.
STEP 5.
Insert an over-the-needle catheter 3 in. (5 cm
for smaller adults; 8 cm for large adult) with
a Luer-Lok 10 cc syringe attached into the
skin. Direct the needle just over the rib into
the intercostal space , aspirating the syringe
while advancing. (Adding 3 cc of saline may
aid the identification of aspirated air.)
STEP 6. Puncture the pleura.
STEP 7. Remove the syringe and listen for the
escape of air when the needle enters the
pleural space to indicate relief of the tension
pneumothorax. Advance the catheter into
the pleural space.
STEP 8. Stabilize the catheter and prepare for chest
tube insertion.
STEP 1.
Finger and Tube
Thoracostomy
STEP 2.
Gather supplies, sterile drapes, and antiseptic,
tube thoracostomy kit (tray) and appropriately
sized chest tube ( 28-32 F). Prepare
the underwater seal and collection device.
Position the patient with the ipsilateral arm
extended overhead and flexed at the elbow
(unless precluded by other injuries). Use an
assistant to maintain the arm in this position.
STEP 3. Widely prep and drape the lateral chest wall,
include the nipple, in the operative field.
STEP 4. Identify the site for insertion of the chest
tube in the 4th or 5th intercostal space.
This site corresponds to the level of the
nipple or inframammary fold. The insertion
site should be between the anterior and
midaxillary lines.
STEP 3. Surgically prepare the site chosen for
insertion. (For pediatric patients, the 2nd
STEP 5.
Inject the site liberally with local anesthesia
to include the skin, subcutaneous tissue,
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