TNCC NOTES FOR WRITTEN EXAM
What is the Mnemonic for the Initial Assessment? A = Airway with simultaneous cervical
spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the patient
warm)ANSWERSWhat is the Mnemonic for the Secondary Assessment? F = Full set of
VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family
presence
G = Give comfort measures (verbal reassurance, touch, and pharmacologic and
nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfacesANSWERSWhere do you listen to auscultate breath sounds?
Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at
the fifth intercostal space at the anterior axillary line.ANSWERSWhat are the late signs of
breathing compromise? - Tracheal deviation
- JVDANSWERSWhat are signs of ineffective breathing? - AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.ANSWERSUpon initial
assessment, what type of oxygen should be used for a pt breathing effectively? A tight-fitting
nonrebreather mask at 12-15 lpm.ANSWERSWhat intervention should be done if a pt presents
with effective circulation? - Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rateANSWERSWhat are
signs of ineffective circulation? - Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart soundsANSWERSWhat are the interventions for Effective/Ineffective
Circulation? - Control any uncontrolled external bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
- Applying pressure over arterial pressure points
- Using tourniquet (last resort).
- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
- Use warmed solution
- Use pressure bags to increase speed of IVF infusion
- Use blood administration tubing for possible administration of blood
- Use rapid infusion device based on protocol
, - Use NS 0.9% in same tubing as blood product
- IV = surgical cut-down, central line, or both.
- Blood sample to determine ABO and Rh group
- IO in sternum, legs, arms or pelvis
- Administer blood products
- PASG (without interfering with fluid resuscitation)ANSWERSHow do you assess Mnemonic
"D"? DISABILITY
A = Alert
V = Verbal
P = Pain
U = Unresponsive
- GCS
- PERRL?
- Determine presence of lateralizing signs including:
- Unilateral deterioration in motor movements or unequal pupils
- Symptoms that help to locate area of injury in brainANSWERSWhat are the interventions for
Disability? - If assessment indicates a decreased LOC, conduct further investigation during
secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider
hyperventilation.ANSWERSWhat is assessed and intervened for Expose/Environmental
Controls? - Remove clothing
- Ensure appropriate decontamination if exposed to hazardous material
- Keep pt warm
- Keep clothing for evidenceANSWERSWhat is the first thing assessed under the Secondary
Assessment? FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE
- ABCDE should be completed
- Labs, X-rays, CT, Foley,
- Family PresenceANSWERSWhat is the second thing assessed under the Secondary
Assessment? GIVE COMFORT MEASURES
- Talking to pt
- Pharmacologic/Nonpharmacologic pain management
- Observe for physical signs of painANSWERSWhat is assessed under the Mnemonic "H"?
HISTORY / HEAD-TO-TOE ASSESSMENT
- MIVT
- M = Mechanism of injury
- I = Injuries sustained
- V = Vital Signs
- T = Treatment
- Pt generated information
- PMH
- Head-to-toe assessmentANSWERSWhat is assessed under the Mnemonic "I"? INSPECT
POSTERIOR SURFACES
- While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and
posterior thighs.
- Palpate vertebral column for deformity and areas of tenderness
, - Assess rectum for presence/absence of tone, presence of bloodANSWERSWhat are factors that
contribute to ineffective ventilation? - AMS
- LOC
- Neurologic injury
- Spinal Cord Injury
- Intracranial Injury
- Blunt trauma
- Pain caused by rib fractures
- Penetrating Trauma
- Preexisting hx of respiratory diseases
- Increased ageANSWERSWhat medications are used during intubation? LOAD Mnemonic:
L = Lidocaine
O = Opioids
A = Atropine
D = Defasiculating agentsANSWERSWhat are the Rapid Sequence Intubation Steps?
PREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds
between attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
POSTINTUBATION MANAGEMENT:
- Secure ET tube
- Set ventilator settings
- Obtain Chest x-ray
- Continue to medicate
- Recheck VS and pulse oxtimetryANSWERSWhat is a Combitube? A dual-lumen, dual-
cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently
placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult
and larger adult.ANSWERSWhat is a Laryngeal Mask Airway? Looks like an ET tube but is
equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to
cover the supraglottic area.
ILMA, does not require laryngoscopy and visualization of the chords.ANSWERSWhat is Needle
Cricothyrotomy Percutaneous transtracheal ventilation. (temporary)
Complications include:
What is the Mnemonic for the Initial Assessment? A = Airway with simultaneous cervical
spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the patient
warm)ANSWERSWhat is the Mnemonic for the Secondary Assessment? F = Full set of
VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family
presence
G = Give comfort measures (verbal reassurance, touch, and pharmacologic and
nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfacesANSWERSWhere do you listen to auscultate breath sounds?
Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at
the fifth intercostal space at the anterior axillary line.ANSWERSWhat are the late signs of
breathing compromise? - Tracheal deviation
- JVDANSWERSWhat are signs of ineffective breathing? - AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.ANSWERSUpon initial
assessment, what type of oxygen should be used for a pt breathing effectively? A tight-fitting
nonrebreather mask at 12-15 lpm.ANSWERSWhat intervention should be done if a pt presents
with effective circulation? - Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rateANSWERSWhat are
signs of ineffective circulation? - Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart soundsANSWERSWhat are the interventions for Effective/Ineffective
Circulation? - Control any uncontrolled external bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
- Applying pressure over arterial pressure points
- Using tourniquet (last resort).
- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
- Use warmed solution
- Use pressure bags to increase speed of IVF infusion
- Use blood administration tubing for possible administration of blood
- Use rapid infusion device based on protocol
, - Use NS 0.9% in same tubing as blood product
- IV = surgical cut-down, central line, or both.
- Blood sample to determine ABO and Rh group
- IO in sternum, legs, arms or pelvis
- Administer blood products
- PASG (without interfering with fluid resuscitation)ANSWERSHow do you assess Mnemonic
"D"? DISABILITY
A = Alert
V = Verbal
P = Pain
U = Unresponsive
- GCS
- PERRL?
- Determine presence of lateralizing signs including:
- Unilateral deterioration in motor movements or unequal pupils
- Symptoms that help to locate area of injury in brainANSWERSWhat are the interventions for
Disability? - If assessment indicates a decreased LOC, conduct further investigation during
secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider
hyperventilation.ANSWERSWhat is assessed and intervened for Expose/Environmental
Controls? - Remove clothing
- Ensure appropriate decontamination if exposed to hazardous material
- Keep pt warm
- Keep clothing for evidenceANSWERSWhat is the first thing assessed under the Secondary
Assessment? FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE
- ABCDE should be completed
- Labs, X-rays, CT, Foley,
- Family PresenceANSWERSWhat is the second thing assessed under the Secondary
Assessment? GIVE COMFORT MEASURES
- Talking to pt
- Pharmacologic/Nonpharmacologic pain management
- Observe for physical signs of painANSWERSWhat is assessed under the Mnemonic "H"?
HISTORY / HEAD-TO-TOE ASSESSMENT
- MIVT
- M = Mechanism of injury
- I = Injuries sustained
- V = Vital Signs
- T = Treatment
- Pt generated information
- PMH
- Head-to-toe assessmentANSWERSWhat is assessed under the Mnemonic "I"? INSPECT
POSTERIOR SURFACES
- While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and
posterior thighs.
- Palpate vertebral column for deformity and areas of tenderness
, - Assess rectum for presence/absence of tone, presence of bloodANSWERSWhat are factors that
contribute to ineffective ventilation? - AMS
- LOC
- Neurologic injury
- Spinal Cord Injury
- Intracranial Injury
- Blunt trauma
- Pain caused by rib fractures
- Penetrating Trauma
- Preexisting hx of respiratory diseases
- Increased ageANSWERSWhat medications are used during intubation? LOAD Mnemonic:
L = Lidocaine
O = Opioids
A = Atropine
D = Defasiculating agentsANSWERSWhat are the Rapid Sequence Intubation Steps?
PREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds
between attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
POSTINTUBATION MANAGEMENT:
- Secure ET tube
- Set ventilator settings
- Obtain Chest x-ray
- Continue to medicate
- Recheck VS and pulse oxtimetryANSWERSWhat is a Combitube? A dual-lumen, dual-
cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently
placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult
and larger adult.ANSWERSWhat is a Laryngeal Mask Airway? Looks like an ET tube but is
equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to
cover the supraglottic area.
ILMA, does not require laryngoscopy and visualization of the chords.ANSWERSWhat is Needle
Cricothyrotomy Percutaneous transtracheal ventilation. (temporary)
Complications include:
