NSG TNCCTNCC Study Guide-converted.
Initial Assessment
● Preparation and Triage
○ Use universal precautions and don PPE
○ Consider any possible patient exposure to hazardous material that puts the trauma team at risk
○ Safe practice, safe care
○ Ensure resuscitation equipment is readily available
● Across the room observation to identify any uncontrolled external hemorrhage
○ Need to reprioritize to Circulation and Control of Hemorrhage
○ Uncontrolled hemorrhage is the major cause of preventable death in trauma patients
● Primary Survey - Inspect, Auscultate, Palpate
○ A: Airway and alertness with cervical spine stabilization
■ AVPU (Alert/verbal stimuli/painful stimuli/unresponsive)
■ Jaw-thrust maneuver to open the airway and assess for obstruction
● Tongue obstruction
● Loose teeth, foreign objects
● Blood, vomitus, secretions
● Edema
■ Listen for obstructive airway sounds (snoring, gurgling, stridor)
■ Feel for subcutaneous emphysema or deformities
■ Definitive Airway devices = ET tube
● Assess for proper placement (ETCO2, bilat breath sounds, absence of
gurgling over the epigastrium)
■ Suction the airway if needed, then reassess
○ B: Breathing and ventilation
■ Are they breathing? How well are they breathing? How long can they keep it up?
■ Spontaneous breathing? Symmetrical rise and fall?
■ Depth, pattern, and rate
■ Skin color
■ Breath sounds
■ Palpate bony structures for possible rib fractures, subcutaneous emphysema, soft tissue injury
■ Open the airway if needed
● Use oral airway adjunct, assist ventilations, then prepare for definitive airway
○ C: Circulation and Control of Hemorrhage
■ Any signs of uncontrolled external bleeding?
● Apply direct pressure or use a tourniquet
■ Skin color, temp, and moisture?
■ Listen to heart and lung sounds
■ Palpate central pulses for rate, rhythm, and strength
■ 2 large-bore IVs
● IO if needed
■ Initiate Warmed isotonic crystalloid solution infusion at a controlled rate
● Consider balanced resuscitation needs
● Rapid infusion protocols
■ Component Therapy = replacing patient loss by administering RBCs, plasma, and platelets
= balanced approach
● Suggested for fluid resuscitation instead of standard approach (large volumes of IV fluids)
○ D: Disability (Neuro status)
■ GCS (not accurate if patient is intubated) and trends
● Eye Opening
,NSG TNCCTNCC Study Guide-converted.
• 4 spontaneous
• 3 to speech
• 2 to pain
,NSG TNCCTNCC Study Guide-converted.
• 1 none
● Verbal Response
• 5 oriented
• 4 confused conversation
• 3 inappropriate words
• 2 incomprehensive words
• 1 none
● Motor Response
• 6 obeys commands
• 5 localizes pain
• 4 withdrawal (normal flexion)
• 3 abnormal flexion (decorticate)
• 2 extension (decerebrate)
• 1 none
■ Assess pupils
■ Need for CT of head and cervical spine?
○ E: Exposure & Environment
■ Remove all clothing
■ Inspect for any uncontrolled bleeding or any obvious injuries
■ Keep the patient warm
● Blankets, fluids, room temp, O2
● Aggressive measures are to be taken to prevent loss of body heat
■ Hypothermia + coagulopathy + acidosis = TRAUMA TRIAD OF DEATH
● Decreased Coagulopathy:
• Trauma induced
• Resuscitation related
● Increased Acidosis
• Reduced pH
• Elevated lactate level
• Excessive fluids (can lead to DIC)
● Hypothermia, decreased heart performance
• Exposure
• Excessive bleeding
• Worsens acidosis
● ** avoiding excess fluids, initiating hemostatic resuscitation, keep pt warm
○ F: Full set of VS and Family presence
■ Monitor effectiveness of resuscitation efforts and trend VS
■ Facilitate family presence as soon as a member of the trauma team is available to act as
a liaison to the family
○ G: Get Resuscitation Adjuncts (Get Stuff!)
■ L: Labs (ABGs, Type and Screen, Lactic Acid)
● Lactic acid is an excellent reflection of tissue perfusion
● Base deficit of -6 is associated with poor outcomes
■ M: Monitor cardiac Rhythm
■ N: Naso or Orogastric tube
■ O: Oxygenation and Ventilation = Pulse ox and ETCO2
● SpO2 > 95%
● ETCO2 norm = 35-45 mmHg
, NSG TNCCTNCC Study Guide-converted.
■ P: Pain
● Assess for pain using appropriate pain scale
Initial Assessment
● Preparation and Triage
○ Use universal precautions and don PPE
○ Consider any possible patient exposure to hazardous material that puts the trauma team at risk
○ Safe practice, safe care
○ Ensure resuscitation equipment is readily available
● Across the room observation to identify any uncontrolled external hemorrhage
○ Need to reprioritize to Circulation and Control of Hemorrhage
○ Uncontrolled hemorrhage is the major cause of preventable death in trauma patients
● Primary Survey - Inspect, Auscultate, Palpate
○ A: Airway and alertness with cervical spine stabilization
■ AVPU (Alert/verbal stimuli/painful stimuli/unresponsive)
■ Jaw-thrust maneuver to open the airway and assess for obstruction
● Tongue obstruction
● Loose teeth, foreign objects
● Blood, vomitus, secretions
● Edema
■ Listen for obstructive airway sounds (snoring, gurgling, stridor)
■ Feel for subcutaneous emphysema or deformities
■ Definitive Airway devices = ET tube
● Assess for proper placement (ETCO2, bilat breath sounds, absence of
gurgling over the epigastrium)
■ Suction the airway if needed, then reassess
○ B: Breathing and ventilation
■ Are they breathing? How well are they breathing? How long can they keep it up?
■ Spontaneous breathing? Symmetrical rise and fall?
■ Depth, pattern, and rate
■ Skin color
■ Breath sounds
■ Palpate bony structures for possible rib fractures, subcutaneous emphysema, soft tissue injury
■ Open the airway if needed
● Use oral airway adjunct, assist ventilations, then prepare for definitive airway
○ C: Circulation and Control of Hemorrhage
■ Any signs of uncontrolled external bleeding?
● Apply direct pressure or use a tourniquet
■ Skin color, temp, and moisture?
■ Listen to heart and lung sounds
■ Palpate central pulses for rate, rhythm, and strength
■ 2 large-bore IVs
● IO if needed
■ Initiate Warmed isotonic crystalloid solution infusion at a controlled rate
● Consider balanced resuscitation needs
● Rapid infusion protocols
■ Component Therapy = replacing patient loss by administering RBCs, plasma, and platelets
= balanced approach
● Suggested for fluid resuscitation instead of standard approach (large volumes of IV fluids)
○ D: Disability (Neuro status)
■ GCS (not accurate if patient is intubated) and trends
● Eye Opening
,NSG TNCCTNCC Study Guide-converted.
• 4 spontaneous
• 3 to speech
• 2 to pain
,NSG TNCCTNCC Study Guide-converted.
• 1 none
● Verbal Response
• 5 oriented
• 4 confused conversation
• 3 inappropriate words
• 2 incomprehensive words
• 1 none
● Motor Response
• 6 obeys commands
• 5 localizes pain
• 4 withdrawal (normal flexion)
• 3 abnormal flexion (decorticate)
• 2 extension (decerebrate)
• 1 none
■ Assess pupils
■ Need for CT of head and cervical spine?
○ E: Exposure & Environment
■ Remove all clothing
■ Inspect for any uncontrolled bleeding or any obvious injuries
■ Keep the patient warm
● Blankets, fluids, room temp, O2
● Aggressive measures are to be taken to prevent loss of body heat
■ Hypothermia + coagulopathy + acidosis = TRAUMA TRIAD OF DEATH
● Decreased Coagulopathy:
• Trauma induced
• Resuscitation related
● Increased Acidosis
• Reduced pH
• Elevated lactate level
• Excessive fluids (can lead to DIC)
● Hypothermia, decreased heart performance
• Exposure
• Excessive bleeding
• Worsens acidosis
● ** avoiding excess fluids, initiating hemostatic resuscitation, keep pt warm
○ F: Full set of VS and Family presence
■ Monitor effectiveness of resuscitation efforts and trend VS
■ Facilitate family presence as soon as a member of the trauma team is available to act as
a liaison to the family
○ G: Get Resuscitation Adjuncts (Get Stuff!)
■ L: Labs (ABGs, Type and Screen, Lactic Acid)
● Lactic acid is an excellent reflection of tissue perfusion
● Base deficit of -6 is associated with poor outcomes
■ M: Monitor cardiac Rhythm
■ N: Naso or Orogastric tube
■ O: Oxygenation and Ventilation = Pulse ox and ETCO2
● SpO2 > 95%
● ETCO2 norm = 35-45 mmHg
, NSG TNCCTNCC Study Guide-converted.
■ P: Pain
● Assess for pain using appropriate pain scale
