Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX G n Skills
STEP 4. If the patient is awake, use a local anesthetic
at the puncture site.
STEP 5. Initially at a 90-degree angle, introduce a
short (threaded or smooth), large-caliber,
bone-marrow aspiration needle (or a short,
18-gauge spinal needle with stylet) into the
skin and periosteum, with the needle bevel
directed toward the foot and away from the
epiphyseal plate.
STEP 6. After gaining purchase in the bone, direct
the needle 45 to 60 degrees away from the
epiphyseal plate. Using a gentle twisting
or boring motion, advance the needle
through the bone cortex and into the
bone marrow.
STEP 7. Remove the stylet and attach to the needle a
10-mL syringe with approximately 6 mL of
sterile saline. Gently draw on the plunger
of the syringe. Aspiration of bone marrow
into the syringe signifies entrance into the
medullary cavity.
STEP 8. Inject the saline into the needle to expel
any clot that can occlude the needle. If the
saline flushes through the needle easily
and there is no evidence of swelling, the
needle is likely located in the appropriate
place. If bone marrow was not aspirated as
outlined in Step 7, but the needle flushes
easily when injecting the saline and there is
no evidence of swelling, the needle is likely
in the appropriate place. In addition, proper
placement of the needle is indicated if the
needle remains upright without support and
intravenous solution flows freely without
evidence of subcutaneous infiltration.
STEP 9. Connect the needle to the large-caliber
intravenous tubing and begin fluid infusion.
Carefully screw the needle further into the
medullary cavity until the needle hub rests
on the patient’s skin and free flow continues.
If a smooth needle is used, it should be
stabilized at a 45- to 60-degree angle to the
anteromedial surface of the patient’s leg.
STEP 10. Apply sterile dressing. Secure the needle
and tubing in place.
STEP 11. Routinely reevaluate the placement of
the intraosseous needle, ensuring that it
remains through the bone cortex and in the
medullary canal. Remember, intraosseous
infusion should be limited to emergency
resuscitation of the patient and discontinued
as soon as other venous access has
been obtained.
Application of Pelvic
Binder or Other Pelvic
Stabilization Device
STEP 1. Select the appropriate pelvic stabilization
device.
STEP 2. Identify the landmarks for application,
focusing on the greater trochanters.
STEP 3. Internally rotate and oppose the ankles, feet,
or great toes using tape or roll gauze.
STEP 4. Slide the device from caudal to cephalad,
centering it over the greater trochanters.
Two people on opposite sides grasp the
device at bottom and top and shimmy it
proximally into position. Alternatively, or
place the device under the patient while
restricting spinal motion and with minimal
manipulation of the pelvis by rotating the
patient laterally. Place folded device beneath
patient, reaching as far beneath patient as
possible. Rotate the other direction and pull
the end of the device through. If using a
sheet, cross the limbs of the sheet and secure
with clamps or towel clamp.
STEP 5. Roll the patient back to supine and secure
the device anteriorly. Ensure that the device
is adequately secured with appropriate
tension, observing internal rotation of lower
limbs, which indicates pelvic closure.
Diagnostic Peritoneal
lAvage (dpl)—OptioNAl
Skill
STEP 1. Obtain informed consent, if time permits.
STEP 2. Decompress the stomach and urinary
bladder by inserting a gastric tube and
urinary catheter.
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