TNCC Review Notes 1
TNCC: Trauma Nursing Core Course
AVPU "alert, verbal, pain, unresponsive"
• A = Airway
- Check for:
□ Tongue obstruction
□ Teeth
□ Vocalization
□ Blood/vomit in airway
□ Edema
- If obstruction Suction…then reassess
- Maintain C-spine precautions
- Prepare for intubation
□ Once intubated assess tube placement by auscultating over
epigastrum first then over lung fields
□ Secure endotracheal tube
• B = Breathing
- Is it spontaneous?
- Accessory muscle use?
- Rate and Pattern?
- Skin color
- Check for bilateral breath sounds
□ If breath sounds are not bilateral consider tube
placement/tension pneumothorax
□ If there is JVD (jugular vein distention) or tracheal deviation
perform needle thoracentisis…
□ Insert large bore needle into the 2nd intercostal space at
the midclavicular line…..prepare for chest tube insertion.
• C = Circulation
- Palpate central pulses (carotid/femoral)
- Check color/temperature/moisture of skin
- Check prehospital IV’s for patency
- Start 2nd large bore IV.
□ Obtain basic labs.
□ Begin infusion of warmed fluid bolus
- Check for obvious signs of external bleeding
□ If obvious signs of external bleeding Control bleeding
• D = Disability
- Check AVPU
□ Alert?
□ Verbal?
□ Responsive to Pain?
□ Unresponsive?
- Check pupils. Are they PERRL?
□ Equal
□ Round
□ Reactive to
□ Light
• E = Expose the patient
, TNCC Review Notes 2
- Remove all clothes
- Examine patient for obvious injuries/bleeding
- Cover the patient
□ Use warm blankets
□ Increase room temperature
• F = Full Set of Vitals/Family Presence/Foley
- Obtain a full set of vitals
- Question about family presence and allow them into room
- Insert foley and/or gastric tube if indicated
• G = Give Comfort
- Obtain a pain rating
- Obtain an order and provide analgesics
- Provide comfort cares of injuries:
□ Ice
□ Elevation
□ Splinting
□ Dressings
• H = History/Head-to-Toe
- Obtain a medical history
- Perform a Head-to-Toe assessment noting all injuries
□ Inspect
□ Auscultate
□ Palpate
• I = Inspect posterior surface/Identify Injuries/Interventions
- Log roll patient maintaining C-spine precautions
□ Inspect and palpate posterior surface
□ MD to check rectal tone
- Identify all injuries to patient
- Consider Interventions
□ CT scan
□ X-ray
□ Basic Labs
□ Ultrasound
• REEVALUATE THE PATIENT
- Primary Assessment
- Vitals
- Pain Level
- Interventions performed
MNENOMICS TO KNOW
• Medications for Intubation: LOAD
- L = Lidocaine (decreases intracranial pressure)
- O = Opiates
- A = Atropine (especially children)
TNCC: Trauma Nursing Core Course
AVPU "alert, verbal, pain, unresponsive"
• A = Airway
- Check for:
□ Tongue obstruction
□ Teeth
□ Vocalization
□ Blood/vomit in airway
□ Edema
- If obstruction Suction…then reassess
- Maintain C-spine precautions
- Prepare for intubation
□ Once intubated assess tube placement by auscultating over
epigastrum first then over lung fields
□ Secure endotracheal tube
• B = Breathing
- Is it spontaneous?
- Accessory muscle use?
- Rate and Pattern?
- Skin color
- Check for bilateral breath sounds
□ If breath sounds are not bilateral consider tube
placement/tension pneumothorax
□ If there is JVD (jugular vein distention) or tracheal deviation
perform needle thoracentisis…
□ Insert large bore needle into the 2nd intercostal space at
the midclavicular line…..prepare for chest tube insertion.
• C = Circulation
- Palpate central pulses (carotid/femoral)
- Check color/temperature/moisture of skin
- Check prehospital IV’s for patency
- Start 2nd large bore IV.
□ Obtain basic labs.
□ Begin infusion of warmed fluid bolus
- Check for obvious signs of external bleeding
□ If obvious signs of external bleeding Control bleeding
• D = Disability
- Check AVPU
□ Alert?
□ Verbal?
□ Responsive to Pain?
□ Unresponsive?
- Check pupils. Are they PERRL?
□ Equal
□ Round
□ Reactive to
□ Light
• E = Expose the patient
, TNCC Review Notes 2
- Remove all clothes
- Examine patient for obvious injuries/bleeding
- Cover the patient
□ Use warm blankets
□ Increase room temperature
• F = Full Set of Vitals/Family Presence/Foley
- Obtain a full set of vitals
- Question about family presence and allow them into room
- Insert foley and/or gastric tube if indicated
• G = Give Comfort
- Obtain a pain rating
- Obtain an order and provide analgesics
- Provide comfort cares of injuries:
□ Ice
□ Elevation
□ Splinting
□ Dressings
• H = History/Head-to-Toe
- Obtain a medical history
- Perform a Head-to-Toe assessment noting all injuries
□ Inspect
□ Auscultate
□ Palpate
• I = Inspect posterior surface/Identify Injuries/Interventions
- Log roll patient maintaining C-spine precautions
□ Inspect and palpate posterior surface
□ MD to check rectal tone
- Identify all injuries to patient
- Consider Interventions
□ CT scan
□ X-ray
□ Basic Labs
□ Ultrasound
• REEVALUATE THE PATIENT
- Primary Assessment
- Vitals
- Pain Level
- Interventions performed
MNENOMICS TO KNOW
• Medications for Intubation: LOAD
- L = Lidocaine (decreases intracranial pressure)
- O = Opiates
- A = Atropine (especially children)
