TNCC: Trauma Nursing Core Course Complete Guide

TNCC Day One  Initial Assessment o Preparation and triage o Primary Survey  Resuscitation adjuncts (F, G) o Reevaluation o Secondary Survey (H, I)  Reevaluation adjuncts o Reevaluation and post resuscitation care o Definitive care or transport  A-I Mnemonic o A- AVPU--airway and alertness with C spine o B- breathing and ventilation (rate) o C- circulation and control of hemorrhage o D- disability (neuro status) o E- exposure and environmental control o F- full set of vital signs and family presence o G- get resuscitation adjuncts (LMNOP- labs, monitor (ekg), OG tube, pain) o H- history and head to toe o I- inspect posterior surfaces  Prep and Triage o Safe practice  PPE  Hazardous exposure o Safe care  Right care- if gunshot wound to chest, get chest tube  Right trauma facility- EMS decides this  Right time- is patient stable enough to transfer  Right resources  Across-the-room- Observation o Uncontrolled hemorrhage is a major cause of preventable death after injury o On arrival, determine the need to reorder ABC to C ABC o Look for uncontrolled EXTERNAL hemorrhage  Look before you start  Look during letter C and E  Also look when doing head-to-toe assessment/roll o First priority is to treat the greatest threat!  A- airway and alertness o Cervical spinal immobilization o Manual stabilization o Spine board primarily a transportation device o First thing we ask, “Is the patient alert and can the patient speak?”  Alert  Verbal  Pain  Unresponsive o Can the patient open and protect the airway? o If patient is unable to open airway  Manually open airway using jaw-thrust  Two person procedure o Inspect for:  Tongue obstructing, loose teeth, foreign objects, blood, vomitus, secretions, edema, burns o Auscultate for:  Obstructive airway sounds- snoring or stridor o Palpate for:  Bony deformity o If a definitive airway is in place, assess for placement and continue assessment (and assess for co2 detector) 2 o Patent airway? o Not patent?  Suction  Remove debris  Airway adjunct  Definitive airway  B- breathing and ventilation o Inspect for:  Spontaneous breathing  Symmetrical rise and fall of the chest  Depth, pattern, and rate of respirations  Signs of respiratory difficulty  Skin color (breathing problems or circulatory problems)  Wounds, contusions, abrasions, or deformities o Auscultate for  Breath sounds  Presence  Quality  Comparison o Palpate for:  Bony structures  Subcutaneous emphysema  Soft tissue injury (bony structures sub q air) o If breathing is absent:  Open the airway  Jaw thrust with second person  Insert an airway adjunct  Assist ventilations with bag mask device  Prepare for definitive airway o If breathing is present:  Administer oxygen  Nonrebreather mask at 15L  Avoid hyperoxia- patient just needs to be above 94% 3  Determine ventilation effectiveness  Use end-tidal CO2 monitoring (best way to monitor ventilation in the quickest way)  If ventilation is ineffective:  Assist ventilations with bag mask  10-12 breaths per min  C- circulation and control of hemorrhage o Hemorrhage: leading cause of preventable death after injury o Continued assessments and high index of suspicion during:  Across the room observation  Primary survey at C  Reevaluation directly following the primary survey  Reevaluation following the second survey o Inspect for:  Uncontrolled EXTERNAL hemorrhage- first step put direct pressure, then tourniquet  Skin color  Palpate for:  Presence of central pulse  Skin temp and moisture  Pulses absent  Initiate basic life support  Assess for cause related to injury o Uncontrolled INTENRAL hemorrhage- we can’t do much about it but we can take them to a trauma surgeon.  If pulses are present, is circulation effective?  Inspect for external hemorrhage, sin color  Palpate for central pulses, rate and rhythm, temp, and moisture  If circulation is ineffective:  Assess for signs of uncontrolled internal hemorrhage 4  Consider such common sites the chest, abdomen, and pelvis o Cannulate two veins o Initiate infusion of warmed isotonic crystalloid solution o Use blood administer tubing o Obtain sample for type and cross match o Consider balanced resuscitation needs o Consider a rapid infusion device o Intervene in life- threatening situations  D- disability (neurologic status) o Inspect pupils  PERRL  So important to get a baseline o Assess Glasgow coma scale  Best eye opening (4)  Best verbal response (5)  Best motor response (6) o Get head CT as quick as can o ABGso Glucose  E- exposure ad environmental control o Assessment  Remove all clothing  Uncontrolled bleeding  Note obvious injuries o Interventions  Evidence of collection  Keep warm  F- Resuscitation adjuncts o Full set of vitals  Trend for changes o Facilitate family presence  Preferred by patients and family 5  Assign a liaison or advocate  G- get resuscitation adjuncts o G- get ADJUNCTS o L- labs o M- monitor for cardiac rhythm and rate assessment o N- naso or orogastric tube consideration o Oxygenation or ventilation analysis o P- pain assessment and ma management  Reevaluation o Suspected uncontrolled internal hemorrhage nu  FAST exam  Chest and pelvis radiographs o Determine need for patient transfer  H-history o M- mech of injury o I- injurers sustained o S- signs and symptoms o T- treatment  Secondary surveyo Head to toe o Inspect for wounds, edema, echymoses, asymmetry o Eyes: gross visual activity, pupils, EOMs o Cerci al spine  immobilize until the injury is cleared o neck: wounds, edema, or contusions  assess position of trachea and note any jugular venous distension  if bowel sounds in the chest, you probably have ruptured diaphragm o abdomen and flanks  wounds, ecchymoses, pain  bowel sounds o pelvis: check for stability