TNCC - Trauma Nursing Core Course
Initial Assessment - ANS 1. Preparation and Triage
2. Primary Survey
3. Reevaluation
4. Secondary Survey
5. Reevaluation Adjuncts
6. Reevaluation and Post Resuscitation Care
7. Definitive Care or Transport
A (Primary Survey) - ANS Airway and alertness with simultaneous cervical spinal
stabilization.
Alertness Assessment - ANS A-Alert
V-Verbal
P-Painful
U-Unresponsive
Airway Assessment - ANS Inspect: tongue obstruction, loose/missing teeth, foreign objects,
blood, vomitus, secretions, edema, burns or evidence of inhalation injury
Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous
emphysema
Airway Interventions: - ANS Suction
Remove foreign body if noted
Jaw thrust maneuver (maintain cspine)
Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)
Consider definitive airway
, A (AVPU) - ANS Alert. Will be able to maintain airway once clear.
V (AVPU) - ANS Verbal. Needs verbal stimuli to respond.
(Airway adjunct may be needed to prevent tongue obstruction)
P (AVPU) - ANS Painful. Responds only to painful stimuli.
(Airway adjunct may be needed while determining need for intubation)
U (AVPU) - ANS Unresponsive. Does not respond to any stimuli.
B (Primary Survey) - ANS Breathing and Ventilation
Breathing and Ventilation Assessment - ANS Inspect: spontaneous breathing, symmetrical
rise and fall, depth/pattern/rate of respirations, accessory muscle use, diaphragmatic
breathing, skin color (normal, pale, flushed, cyanotic), contusions/abrasions/deformities
(signs of underlying injury), open pneumothoraces (sucking chest wound), JVD, tracheal
position, signs of inhalation injury
Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space
midclavicular line and bases at the fifth intercostal space anterior axillary line
Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV
pulsations at suprasternal notch or supraclavicular area
Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax,
tension pneumothorax, flail chest, hemothorax.
Breathing and Ventilation Intervention - ANS Breathing absent: jaw-thrust maneuver, oral
airway adjunct, assist ventilation with bag-mask device, prepare for definitive airway
Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or
higher. If ineffective: assist with bag-mask and determine need for definitive airway
Initial Assessment - ANS 1. Preparation and Triage
2. Primary Survey
3. Reevaluation
4. Secondary Survey
5. Reevaluation Adjuncts
6. Reevaluation and Post Resuscitation Care
7. Definitive Care or Transport
A (Primary Survey) - ANS Airway and alertness with simultaneous cervical spinal
stabilization.
Alertness Assessment - ANS A-Alert
V-Verbal
P-Painful
U-Unresponsive
Airway Assessment - ANS Inspect: tongue obstruction, loose/missing teeth, foreign objects,
blood, vomitus, secretions, edema, burns or evidence of inhalation injury
Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous
emphysema
Airway Interventions: - ANS Suction
Remove foreign body if noted
Jaw thrust maneuver (maintain cspine)
Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)
Consider definitive airway
, A (AVPU) - ANS Alert. Will be able to maintain airway once clear.
V (AVPU) - ANS Verbal. Needs verbal stimuli to respond.
(Airway adjunct may be needed to prevent tongue obstruction)
P (AVPU) - ANS Painful. Responds only to painful stimuli.
(Airway adjunct may be needed while determining need for intubation)
U (AVPU) - ANS Unresponsive. Does not respond to any stimuli.
B (Primary Survey) - ANS Breathing and Ventilation
Breathing and Ventilation Assessment - ANS Inspect: spontaneous breathing, symmetrical
rise and fall, depth/pattern/rate of respirations, accessory muscle use, diaphragmatic
breathing, skin color (normal, pale, flushed, cyanotic), contusions/abrasions/deformities
(signs of underlying injury), open pneumothoraces (sucking chest wound), JVD, tracheal
position, signs of inhalation injury
Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space
midclavicular line and bases at the fifth intercostal space anterior axillary line
Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV
pulsations at suprasternal notch or supraclavicular area
Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax,
tension pneumothorax, flail chest, hemothorax.
Breathing and Ventilation Intervention - ANS Breathing absent: jaw-thrust maneuver, oral
airway adjunct, assist ventilation with bag-mask device, prepare for definitive airway
Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or
higher. If ineffective: assist with bag-mask and determine need for definitive airway
