Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX G n Skills
STEP 3. After donning a mask, sterile gown, and
gloves, surgically prepare the abdomen
(costal margin to the pubic area and flank
to flank, anteriorly).
STEP 4. Inject local anesthetic containing
epinephrine in the midline just below the
umbilicus, down to the level of the fascia.
Allow time to take affect.
retroperitoneal injuries such as pancreatic
and duodenal injuries.
Femoral Venipuncture:
Seldinger Technique—
Optional Skill
STEP 5.
Vertically incise the skin and subcutaneous
tissues to the fascia.
Note: Sterile technique should be used when performing
this procedure.
STEP 6. Grasp the fascial edges with clamps, and
elevate and incise the fascia down to the
peritoneum. Make a small nick in the
peritoneum, entering the peritoneal cavity.
STEP 7. Insert a peritoneal dialysis catheter into the
peritoneal cavity.
STEP 8. Advance the catheter into the pelvis.
STEP 9. Connect the dialysis catheter to a syringe
and aspirate.
STEP 10. If gross blood or organic matter is aspirated,
the patient should be taken for laparotomy.
If gross blood is not obtained, instill 1 L of
warmed isotonic crystalloid solution (10 mL/
kg in a child) into the peritoneum through
the intravenous tubing attached to the
dialysis catheter.
STEP 11. Gently agitate the abdomen to distribute the
fluid throughout the peritoneal cavity and
increase mixing with the blood.
STEP 12. If the patient’s condition is stable, allow
the fluid to remain a few minutes before
placing the intravenous fluid bag on
the floor and allowing the peritoneal
fluid to drain from the abdomen.
Adequate fluid return is > 20% of the
infused volume.
STEP 13. After the fluid returns, send a sample to the
laboratory for Gram stain and erythrocyte
and leukocyte counts (unspun). A positive
test and thus the need for surgical
intervention is indicated by 100,000 red
blood cells (RBCs)/mm 3 or more, greater
than 500 white blood cells (WBCs)/mm 3 ,
or a positive Gram stain for food fibers or
bacteria. A negative lavage does not exclude
STEP 1.
Place the patient in the supine position.
STEP 2. Cleanse the skin around the venipuncture
site well and drape the area.
STEP 3. Locate the femoral vein by palpating
the femoral artery. The vein lies directly
medial to the femoral artery (remember the
mnemonic NAVEL, from lateral to medial:
nerve, artery, vein, empty space, lymphatic).
Keep a finger on the artery to facilitate
anatomical location and avoid insertion of
the catheter into the artery. Use ultrasound
to identify the femoral artery and visualize
placement of needle into the vein.
STEP 4. If the patient is awake, use a local anesthetic
at the venipuncture site.
STEP 5.
Introduce a large-caliber needle attached to
a 10-mL syringe with 0.5 to 1 mL of saline.
Direct the needle toward the patient’s head,
entering the skin directly over the femoral
vein. Hold the needle and syringe parallel
to the frontal plane.
STEP 6. Directing the needle cephalad and posteriorly,
slowly advance it while gently withdrawing
the plunger of the syringe.
STEP 7. When a free flow of blood appears in the
syringe, remove the syringe and occlude the
needle with a finger to prevent air embolism.
If the vein is not entered, withdraw the
needle and redirect it. If two attempts are
unsuccessful, a more experienced clinician
should attempt the procedure, if available.
STEP 8. Insert the guidewire and remove the needle.
STEP 9. Make a small skin incision at the entry point
of wire, pass the dilator (or dilator introducer
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