Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX G n Skills
STEP 2. If the patient is awake, use a local anesthetic
at the venipuncture site.
STEP 3. Make a full-thickness, transverse skin incision
through the anesthetized area to a
length of 1 inch (2.5 cm).
STEP 4.
By blunt dissection, using a curved hemostat,
identify the vein and dissect it free from any
accompanying structures.
STEP 5. Elevate and dissect the vein for a distance
of approximately 3/4 inch (2 cm) to free it
from its bed.
STEP 6. Ligate the distal mobilized vein, leaving the
suture in place for traction.
STEP 7. Pass a tie around the vein in a cephalad
direction.
STEP 8. Make a small, transverse venotomy and
gently dilate the venotomy with the tip of a
closed hemostat.
STEP 9. Introduce a plastic cannula through the
venotomy and secure it in place by tying the
upper ligature around the vein and cannula.
To prevent dislodging, insert the cannula an
adequate distance from the venotomy.
STEP 10. Attach the intravenous tubing to the
cannula, and close the incision with
interrupted sutures.
STEP 11. Apply a sterile dressing.
STEP 1.
PericARdiocentesis Using
UltRAsound—Optional
Skill
Monitor the patient’s vital signs and electrocardiogram
(ECG) before, during, and after
the procedure.
STEP 2. Use ultrasound to identify the effusion.
STEP 3. Surgically prepare the xiphoid and
subxiphoid areas, if time allows.
STEP 4. Locally anesthetize the puncture site,
if necessary.
STEP 5. Using a 16- to 18-gauge, 6-in. (15-cm) or
longer over-the-needle catheter, attach
a 35-mL empty syringe with a threeway
stopcock.
STEP 6. Assess the patient for any mediastinal shift
that may have caused the heart to shift
significantly.
STEP 7.
Puncture the skin 1 to 2 cm inferior to the left
of the xiphochondral junction, at a 45-degree
angle to the skin.
STEP 8. Carefully advance the needle cephalad and
aim toward the tip of the left scapula. Follow
the needle with the ultrasound.
STEP 9. Advance the catheter over the needle.
Remove the needle.
STEP 10. When the catheter tip enters the bloodfilled
pericardial sac, withdraw as much
nonclotted blood as possible.
STEP 11. After aspiration is completed, remove the
syringe and attach a three-way stopcock,
leaving the stopcock closed. The plastic
pericardiocentesis catheter can be sutured
or taped in place and covered with a
small dressing to allow for continued
decompression en route to surgery or
transfer to another care facility.
STEP 12. If cardiac tamponade symptoms persist, the
stopcock may be opened and the pericardial
sac reaspirated. This process may be repeated
as the symptoms of tamponade recur, before
definitive treatment.
Links to Future LeARNing
Shock can develop over time, so frequent reassessment
is necessary. Hemorrhage is the most common cause
of shock in the trauma patient, but other causes
can occur and should be investigated. The MyATLS
mobile app provides video demonstrations of most
procedures. Also visit www.bleedingcontrol.org for
more information regarding external hemorrhage
control. Visit https://www.youtube.com/watch?v=Wu-
KVibUGNM to view a video demonstrating the humeral
intraosseous approach, and https://www.youtube.
com/watch?v=OwLoAHrdpJA to view video of the
ultrasound-guided approach to pericardiocentesis.
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