Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX G n Skills
combination) over the wire and remove the
dilator holding pressure at the exit site of
the wire (or remove dilator if introducer
combination is used).
STEP 10. Insert the catheter over the guidewire
aspirate to assure free blood flow. If using
an introducer, aspirate it.
STEP 11. Flush the catheter or introducer with saline
and cap or begin fluid infusion
STEP 12. Affix the catheter in place (with a suture),
dress the area according to local protocol.
STEP 13. Tape the intravenous tubing in place.
STEP 14. Change the catheter location as soon as it
is practical.
Subclavian Venipuncture:
InfRAclaviculAR Approach—
Optional Skill
Note: Sterile technique should be used when performing
this procedure.
STEP 1. Place the patient in the supine position,
with the head at least 15 degrees down
to distend the neck veins and prevent
air embolism. Only if a cervical spine
injury has been excluded can the
patient’s head be turned away from the
venipuncture site.
STEP 2. Cleanse the skin around the venipuncture
site well, and drape the area.
STEP 3. If the patient is awake, use a local anesthetic
at the venipuncture site.
STEP 4. Introduce a large-caliber needle, attached to
a 10-mL syringe with 0.5 to 1 mL of saline,
1 cm below the junction of the middle and
medial one-third of the clavicle.
STEP 7.
Direct the needle medially, slightly cephalad,
and posteriorly behind the clavicle toward
the posterior, superior angle of the sternal
end of the clavicle (toward the finger placed
in the suprasternal notch).
STEP 8. Slowly advance the needle while gently
withdrawing the plunger of the syringe.
STEP 9. When a free flow of blood appears in the
syringe, rotate the bevel of the needle,
caudally 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 (if available) should attempt
the procedure.
STEP 10. Insert the guidewire while monitoring the
electrocardiogram for rhythm abnormalities.
STEP 11. Remove the needle while holding the
guidewire in place.
STEP 12. Use an 11 blade to incise the skin around
the exit site of the guidewire. Insert
the dilator over the guidewire to dilate
the area under the clavicle. Remove
the dilator, leaving the wire in place.
Thread the catheter over the wire to a
predetermined depth (the tip of the catheter
should be above the right atrium for
fluid administration).
STEP 13. Connect the catheter to the intravenous
tubing.
STEP 14. Affix the catheter securely to the skin (with
a suture), dress the area according to local
protocol.
STEP 15. Tape the intravenous tubing in place.
STEP 16. Obtain a chest x-ray film to confirm the
position of the intravenous line and identify a
possible pneumothorax.
STEP 5.
After the skin has been punctured, with the
bevel of the needle upward, expel the skin
plug that can occlude the needle.
Venous Cutdown
Optional Skill
STEP 6. Hold the needle and syringe parallel to the
frontal plane.
STEP 1.
Cleanse the skin around the site chosen for
cutdown, and drape the area.
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