TNCC - 7th Ed. - Chapter 5 - Initial Assessment

The ___ Mnemonic helps the trauma nurse rapidly assess for and intervene in the life-threatening injuries and identify all injuries in a systematic manner. A-I Mnemonic What is the A in the primary assessment? Airway and Alertness with simultaneous cervical spinal stabilization What is the B in the primary assessment? Breathing and Ventilation What is the C in the primary assessment? Circulation and Control of hemorrhage What is the D in the primary assessment? Disability (Neurologic status) What is the E in the primary assessment? Exposure and Environmental control What is the F in the primary assessment? Full set of vital signs and Family presence What is the G in the primary assessment? Get resuscitation adjuncts: LMNOP What is the H in the primary assessment? History and Head-to-Toe assessment What is the I in the primary assessment? Inspect posterior surfaces What is the L in the LMNOP mnemonic for Get resuscitation adjuncts? Labs, ABG and Type and Cross What is the M in the LMNOP mnemonic for Get resuscitation adjuncts? Monitor for continuous cardiac rhythm and rate assessment What is the N in the LMNOP mnemonic for Get resuscitation adjuncts? Naso or Orogastric tube consideration What is the O in the LMNOP mnemonic for Get resuscitation adjuncts? Oxygenation and ventilation analysis: pulse ox, ETCO2 monitoring or capnography What is the P in the LMNOP mnemonic for Get resuscitation adjuncts? Pain assessment and management When does the approach to trauma care begin? With notification that a trauma patient is arriving in the ED ___ means taking into consideration the protection of the team. Safe Practice What is included in safe practice when preparing to receive a trauma patient? Observing universal precautions Donning PPE prior to arrival Consideration of any potential exposure to hazardous material that may put the trauma team, other patients and ED or hospital at risk ___ means assuring the patient is getting to the right hospital in the right amount of time for the right care. Safe Care ___ refers to the "golden hour" Right Time Optimal outcomes result when time in the field is minimized and care is focused on ___. airway maintenance, control of hemorrhage and immobilization ___ involves the sorting of patients based on their need for treatment and the resources available to provide that treatment. Triage The primary survey begins immediately upon the patient's arrival to the trauma room with an ___. Across-the-room Observation ___ can allow for rapid determination of the patient's overall physiologic stability and the identification of any uncontrolled external hemorrhage. Across-the-room observation During the primary survey, ___ are identified and immediately corrected. Life-threatening conditions What is the major cause of preventable death after injury? Uncontrolled hemorrhage The Department of Defense teaches the mnemonic MARCH for primary assessment which stands for what? Massive Hemorrhage Airway Respiration Circulation Head injury / Hypothermia What is the best way to assess airway and alertness? Talk to the patient A C-spine injury is suspected in any patient with multisystem trauma until the patient has ___. A GCS of 15 and has been fully evaluated for C-Spine injury by an experienced physician or has been cleared of spinal injury by CT or radiography. What are the two ways to accomplish cervical spine alignment and protection? Manual stabilization Immobilization How is manual stabilization of the cervical spine accomplished? Two hands holding the patient's head and neck in alignment How is cervical spine immobilization accomplished? A correctly sized, semi-rigid cervical collar securely fastened The spine board is primarily a ___. Transportation device Remove the spine board as soon as ___. A spinal cord injury has been ruled out Removal of a helmet requires ___. Two people What are the components of AVPU, which is used to quickly assess a patient's level of alertness? A - Alert - If the patient is alert, he will be able to maintain the airway once it's clear. V - Verbal - If the patient needs verbal stimuli to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway P - Pain - If the patient responds only to pain, he may not be able to maintain his airway and an airway adjunct may need to be placed while further assessing to determine a need for intubation U - Unresponsive - If the patient is unresponsive, direct someone to check for a pulse while assessing if the cause of the problem is the airway If the AVPU is any level except A, the airway may be ___. Compromised What do you do if a patient is unresponsive upon arrival? Announce it loudly to the team and direct someone to see if the patient is pulse-less. During A of the primary survey, after AVPU has been determined that the patient is ALERT, and while C-spine precautions are maintained, ask the patient to ___. Open his or her mouth During airway assessment, if the patient is unable to open their mouth or is anything but A on AVPU, what do you do to open the airway? Jaw-thrust maneuver If the patient has a suspected cervical-spine injury, jaw thrust is performed by ___. Two Providers Describe the two provider jaw thrust maneuver. One person provides manual stabilization of the cervical spine and the second performs the jaw thrust procedure What is the airway inspected for? Tongue obstruction Loose or missing teeth Foreign objects Blood, vomitus or secretions Edema Burns or evidence of inhalation injury What is the airway auscultated for? Obstruction sounds such as snoring, gurgling or stridor What is the airway palpated for in the primary survey? Possible occlusive maxillofacial bony deformity Subcutaneous emphysema What airway opening maneuver is NOT used in a trauma patient? Head-tilt / Chin-Lift During the airway assessment in the primary survey, what do you do if the patient has a definitive airway in place? Assess for proper placement What are proper placement findings of a definitive airway? Adequate rise and fall of the chest with assisted ventilation Absence of gurgling on auscultation over epigastrium Bilateral breath sounds on auscultation CO2 detected on device If the patient is awake and has a patent airway, they may assume a position that ___. Facilitates adequate air exchange What is the first step if the airway is NOT patent on airway assessment in the primary survey? Suction the airway When suctioning the airway, avoid ___. Stimulating the gag reflex How do you remove a foreign body that is obstructing an airway? Carefully with forceps If suctioning does not relieve the airway obstruction, what may be causing it? The tongue A ___ can be used in patients who are conscious or unconscious. Nasopharyngeal ariway A ___ can be used in patients without a gag reflex. Oropharyngeal airway If suctioning does not remove the airway obstruction, what should you do? Perform jaw-thrust maneuver and insert an airway adjunct After inserting an airway adjunct, what should be considered? Placement of a definitive airway What is the term for a tracheal tube securely placed in the trachea with the cuff inflated? Definitive Airway ___ tubes are now recommended for children under 8 years of age. Cuffed List the situations that require a definitive airway. Apnea GCS8 Severe maxillofacial fractures Evidence of inhalation injury Laryngeal or tracheal injury or neck hematoma High risk of aspiration and the patient's inability to protect the airway Compromised or ineffective ventilation Anticipation of deterioration of neurologic status that may result in an inability to maintain or protect the airway What do you do if injury or anatomic variations make it difficult to successfully intubate a patient during the airway assessment of the primary survey? Continue to ventilate the patient with Bag-Mask Device connected to oxygen at 15L/min until an alternative airway can be established. To assess a patient's breathing, ___ and complete the inspection, auscultation and palpation assessments. Expose the patient's chest What are you inspecting for during the assessment of breathing in the primary survey? Spontaneous breathing Symmetrical rise and fall of the chest Depth, pattern and rate of respirations Skin color Signs of respiratory difficulty (diaphragmatic breathing, use or accessory muscles) Contusions, abrasions or deformities that may be a sign of underlying injury Open pneumothroaces (sucking chest wounds) JVD Position of the trachea Signs of inhalation injury (singed nasal hairs, carbonaceous sputum) During auscultation of breathing in the primary survey, what are you looking for? Presence, quality and equality of breath sounds bilaterally Heart sounds Where should auscultation of breath sounds be performed during breathing assessment in the primary survey? 2nd intercostal space and midclavicular line Bases at 5th intercostal space at the anterior axillary line During assessment of breathing in the primary survey, what do you palpate for? Bony structures and possible rib fractures, which may impact ventilation Subcutaneous emphysema (may be a sign of a pneumothorax) Soft tissue injury Jugular venous pulsations at the suprasternal notch or in the supraclavicular area What are the steps you take if breathing is absent during the primary survey? Open the airway using jaw-thrust while maintaining cervical spine stabilization Insert oral airway adjunct Assist ventilation's with a bag-mask Prepare for a definitive airway When assessing breathing in the primary survey, what is the first intervention you take for a patient who is breathing? Administer 15L/min oxygen via nonrebreather mask Inability to maintain adequate oxygenation causes hypoxemia resulting in ___. anaerobic metabolism and acidosis Trauma patients need early supplemental oxygen, however, recent evidence suggests to closely monitor and titrate oxygen delivery for stabilized trauma patients to avoid detrimental ___. Effects of hyperoxia After administering oxygen via nonrebreather mask in a patient who is breathing, what do you do? Determine if ventilation is effective How do you determine if ventilation is effective? ETCO2 measurement between 35 and 45 O2 Sat of 94% or higher What does a ETCO2 level 50 signify? Depressed ventilation After administering oxygen via nonrebreather mask and assessing for effective ventilation, if ventilation is ineffective what should you do? Assist ventilation with bag-mask and oxygen at 15L/min at 10-12 breaths per minute or a breath every 5-6 seconds Determine the need for a definitive airway What rate are breaths delivered at via bag-mask? One breath every 5-6 seconds or 10-12 breaths per minute What life-threatening injuries should be identified during the breathing assessment of the primary survey? Open pneumothorax Tension pneumothorax Flail chest Hemothorax Which injuries require intervention before moving to the circulation step in the primary survey? Open pneumo, tension pneumo, flail chest and hemothorax What are the three major assessment parameters pertaining to circulation that produce important information within seconds of a patient's arrival? Level of consciousness Skin color Pulse The assessment of circulation during the primary survey includes early evaluation of the possibility of ___. Hemorrhage in the abdomen or pelvis in any patient who sustained blunt trauma. In cases of blunt trauma to abdomen or pelvis, a ___ is performed. FAST exam or pelvic xray After the primary survey circulation assessment, even if hemorrhage is controlled, what do you do? Come back to circulation assessment During the circulation assessment in the primary survey, what do you inspect for? Uncontrolled external bleeding Skin color During the circulation assessment in the primary survey, what do you auscultate for? Muffled heart sounds, which may indicate pericardial tamponade During the circulation assessment in the primary survey, what do you palpate for? Presence of carotid and/or femoral (central) pulses for rate, rhythm and strength Skin temperature and moisture (cool and diaphoretic or warm and dry)